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Personal Accident and Illness Insurance Online Quote Form

 

Please complete the following information and submit this form to obtain an insurance quotation for personal accident and/or illness. Click on the following if you require trades insurance including public liability.

 

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

 

Please refer to the CGIB Financial Services Guide, Privacy Statement, General Advice Warning and Duty of Disclosure before completing this form.

INSURED'S - Details
 

  Insured Name*

 

  Address*

 City/Town*

Post Code*

  Postal Address

 City/Town*

Post Code*

Occupation*

Briefly describe the products and/or services your business provides*
 

 COVER – Details
 

PERSONAL ACCIDENT

  

Average Weekly Income*

Less overtime/bonuses/commission  
Fixed business expenses   e.g. payment for leasing equipment, employees wages, rent, insurance, payroll tax etc.
Non fixed business expenses  

Date of Birth*

/ /

Height*

cm's

Weight*

kg's

Personal Illness required

Excluded Period of Claim   (waiting time prior to claiming)
Benefit Period (Time on claim)
Type of Cover

Do you Smoke?

In current business less than 12months?

 

 PREVIOUS INSURANCE - Details
 
Currently Insured? if yes, please provide the date it expirers / / & The Insurer*
   

Have you ever claimed for benefits under any accident or illness policy?

   

 INSURANCE - Details
   
Is the Person to be insured entitled to claim benefit from Work Cover?
Is the Person to be insured entitled to claim benefits from any other existing or intended injury or illness insurance policy?

Has any policy, or application, for injury or illness insurance concerning the Person to be insured ever been declined, modified,
accepted at an increased premium, cancelled or refused renewal?

Has the Person to be insured ever claimed benefits from Work Cover?

 

Has the Person to be insured ever claimed benefits under injury or illness insurance policy?

 

   

 MEDICAL - Details
   
Has the Person to be insured in the last 10 years received treatment or advice from a Registered Medical Practitioner (including but not limited to a doctor, chiropractor, physiotherapist or naturopath) in relation to:
   
Heart, arteries, high cholesterol or high blood pressure or disorders of the circulatory system?
Lungs, asthma, tuberculosis or disorders of the respiratory system?
Kidney, bladder, liver, spleen, bowel or disorders of the genito-urinary system?
Brain, Epilepsy or disorder of the central nervous system?
Stomach, esophagus or disorders of the digestive system?

Head, back, neck or spine or any disorder of the musculoskeletal system?

 

Depression, psychological, psychiatric or personality disorder?

 

Drug or alcohol dependence?

 

Cancer or Tumour?

 

Diabetes?

 

HIV, AIDS or AIDS related conditions?

 

Any disorder of the Eyes or Ears?

 

Hepatitis?

 

Any hernia or associated condition?

 

Ulcers?

 

Arthritis or rheumatism?

 

Physical impairment or deformity?

 
   

Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?

 

 

 ACTIVITY – Details
 
Does the Person to be insured participate (or intend to participate) in any hazardous pursuit or activities, including but not limited to motor sports in any form, rock climbing or mountaineering, water skiing, snow skiing, snow boarding, horse riding, canyoning, motor cycling, parachuting, abseiling, kite surfing, mountain biking, scuba diving, football of any code or any other body contact sports?
 

 CONTACT – Details
 

First Name*

Surname*

  Phone No

   (please include area code)

  Fax No

   (please include area code)

Email Address*

 

How did you find us?*
if other, please provide details

 

 

 

 

 * Mandatory Fields

Thanks for completing our online form.

We will endeavour to contact you with your insurance details soon.

Meanwhile, if you require any further assistance please feel free to contact us.

            

                                                                                          

 

We may need to contact you to obtain additional information to provide you with an insurance quotation.

Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.